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1
Hyperglycemic Emergency Management (DKA/HHS ) - Adult
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into co nsideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers .

PATIENT WORKUP/
PRESENTATION ASSESSMENT ● Consult
Endocrinology
Yes service
Assess4 the following: ● See Page 2
● History and physical ● Hydration status Diagnosis for DKA/HHS
● Arterial blood gas
● Basic metabolic ● Electrolyte status
of hyperglycemic Management
● Capillary blood
panel, calcium, ● Blood Glucose
glucose every hour emergency5?
Patient with phosphorus and ● Acidosis
magnesium Yes ● Calculate anion gap
history of Serum
Type 1 or 2 every 4 hours Continue work
● Capillary blood bicarbonate up for further
Diabetes Mellitus less than 15 mEq/L or
glucose every hour No treatment or
or presenting with 2
respiratory rate greater
● Urine ketones
polyuria, alternative
● Ionized calcium than 16 breaths per
polydipsia, nausea/ diagnosis
● Diagnostic imaging minute?
vomiting, or as clinically indicated
abdominal pain
Note: Interventions3 for No
urinary output, pH, and
serum bicarbonate Continue to monitor hourly
capillary blood glucose as per
protocol (See Appendix A and B)

1
Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS)
2
If urine ketones are positive, send serum beta-hydroxybutyrate, and start treatment pending results
3
Interventions:
● Strict input and output hourly for a total of 4 hours and notify physician if urine output is less than 0.5 mL/kg/hour
● If pH is less than 7 or if serum bicarbonate is less than 10 mEq/L, notify physician
4
Continue to look for the underlying cause of events
5
DKA diagnostic criteria: blood glucose greater than 250 mg/dL, arterial pH less than 7.3, bicarbonate less than 15 mEq/L, and moderate ketonuria or ketonemia
HHS diagnostic criteria: blood glucose greater than 600 mg/dL, arterial pH greater than7.3, bicarbonate greater than 15 mEq/L, and minimal ketonuria and ketonemia
Department of Clinical Effectiveness V2
Approved by the Executive Committee of the Medical Staff on 12/12/2017
 Page 2 of 6
Hyperglycemic Emergency Management (DKA/HHS) - Adult
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into co nsideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers .

DKA/HHS TREATMENT INTERVENTION

Management Corrected sodium Additional fluids of
less than 147 mEq/L 0.9% sodium chloride When blood glucose is less than
1 or equal to 250 mg/dL, change
0.9% sodium chloride 1 liter IV Calculate
Hydration over 1 hour, then initiate continuous corrected Corrected sodium IVF to D5 0.45% sodium
infusion to replete volume status sodium2 greater than or Additional fluids of chloride to infuse at current rate
equal to 147 mEq/L 0.45% sodium chloride

Replete and recheck potassium per electrolyte Once potassium greater than 3.3 mEq/L,
Potassium less than give regular insulin 0.15 units/kg IV bolus5
3.3 mEq/L replacement4 protocol. If protocol contraindicated or ● Recheck
not ordered, notify physician. and start regular insulin 0.1 units/kg/hour
potassium
IV infusion3,6
and
Potassium Give regular insulin 0.15 units/kg IV bolus5 and electrolytes
Potassium
3.3-5.5 mEq/L start regular insulin 0.1 units/kg/hour IV infusion3 every 4 hours
and
● See Page 3
initiation
● Notify ICU team for Insulin
of insulin3 Potassium greater ● Stop all sources of potassium administration and treat hyperkalemia as clinically indicated Titration
than 5.5 mEq/L ● Give regular insulin 0.15 units/kg IV bolus5 and start regular insulin 0.1 units/kg/hour IV infusion3
● Repeat serum potassium every 2 hours until less than 5.5 mEq/L

Greater than 7.14 No need to give sodium bicarbonate

6.9 - 7.14 Consider sodium bicarbonate Recheck blood gas hourly for pH and
pH
(as per ICU team management) bicarbonate until pH reaches 7.2 or higher

Less than 6.9 Treat with sodium bicarbonate

(as per ICU team management)
1
Consider reduction for patients with heart failure, end-stage liver or renal disease, or greater than 65 years old
2
Calculation for corrected sodium = 0.016 x (measured glucose – 100) plus measured Na
3
Prime all insulin tubing with 25 units of insulin from bag and do not use a manifold
4
Refer to the Critical Care Adult PRN Electrolyte Replacement Orders via CVC protocol
5
For insulin management with regular insulin bolus: usual dose 10-15 units for patients 70 to 100 kg
6
Consider reducing insulin dose for patients with end-stage liver or renal disease Department of Clinical Effectiveness V2
Approved by the Executive Committee of the Medical Staff on 12/12/2017
 Page 3 of 6
Hyperglycemic Emergency Management (DKA/HHS) - Adult
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into co nsideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers .

INSULIN TITRATION
● Notify ICU/EC Team and change IVF to D5 0.45% sodium chloride
Yes to infuse at current rate
● Decrease insulin infusion rate by half See
Blood glucose ● Titrate insulin infusion per Appendix B Long Acting
Insulin
less than or equal to Insulin
Titration 1 250 mg/dL? Management
below
No Continue to monitor capillary blood glucose every hour and titrate insulin infusion per Appendix A

LONG ACTING INSULIN MANAGEMENT

● Insulin glargine 0.1 units/kg

Yes ● Consider reducing dose in patients
Initiation of long- with end stage liver failure
acting insulin
once electrolytes
are corrected and ● Notify Endocrinology eGFR less than
blood glucose service 60 mL/minute/1.73 m2 ● Insulin glargine 0.15 units/kg Discontinue insulin
levels between ● Endocrinology to dose or age greater BMI less than 30 ● Consider reducing dose in infusion 2 hours after
150-250 mg/dL long-acting insulin than 70 years? patients with end stage liver failure long-acting insulin
for 2 consecutive No administration
hours as per
Appendix B BMI 30 or greater or ● Insulin glargine 0.2 units/kg
taking more than ● Consider reducing dose in patients
1 unit/kg/day with end stage liver failure
eGFR = estimated glomerular filtration rate
1 insulin dose at home
Prime all insulin tubing with 25 units of insulin from bag and do not use a manifold

Department of Clinical Effectiveness V2

Approved by the Executive Committee of the Medical Staff on 12/12/2017
 Page 4 of 6
Hyperglycemic Emergency Management (DKA/HHS) - Adult
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into co nsideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers .

APPENDIX B:
Blood Glucose and Insulin Drip Titration for Blood Glucose Less Than or Equal to 250 mg/dL
APPENDIX A: Glucose Insulin Drip Management 1. Decrease insulin continuous IV infusion rate by half of current dose (if not already done)
for Blood Glucose Greater Than 250 mg/dL 2. Once blood glucose is less than or equal to 250 mg/dL, start insulin drip titration
Glucose Level Intervention Recheck Glucose Glucose Level Intervention Recheck Glucose
● Decreased by less than ● Stop infusion, notify physician, and give D50W 25 mL IV push
50 mg/dL or increased by Less than 70 mg/dL ● Restart infusion at half the previous rate when glucose is greater 1 hour
any amount Double infusion rate 1 hour post change than 180 mg/dL on 1 measurement
● And remains greater than ● Stop infusion
250 mg/dL 70-90 mg/dL ● Restart infusion at half the previous rate when glucose is greater 1 hour
than 180 mg/dL on 1 measurement
Decreased by 50-100 mg/dL 91-120 mg/dL Decrease infusion rate by half the current rate 1 hour
and remains greater than Continue current rate 1 hour post change
121-140 mg/dL Decrease infusion rate by 1 unit/hour 1 hour
250 mg/dL
● No change
Decreased greater than 141-180 mg/dL ● If no changes are needed for 3 consecutive measurements, 1 hour
100 mg/dL and remains Decrease rate by half 1 hour post change decrease monitoring to every 2 hours
greater than 250 mg/dL ● If glucose increasing, increase infusion rate by 1 unit/hour
181-200 mg/dL ● If glucose decreasing or the same, continue current rate
1 hour
Once blood glucose is less than or equal to 250 mg/dL: ● If glucose increasing, increase infusion rate by 1.5 units/hour
● Decrease insulin infusion rate by half and
201-250 mg/dL ● If glucose decreasing or the same, continue current rate
1 hour
● Notify ICU/EC team to change IV fluids to D5 0.45% sodium chloride ● If glucose increasing, increase infusion rate by 2 units/hour
and activate Appendix B Insulin Drip Management Orders 251-300 mg/dL ● If glucose decreasing or the same, continue current rate
1 hour
● If glucose increasing, give regular insulin 10 units IV push
301-350 mg/dL and increase infusion rate by 2 units/hour 1 hour
● If glucose decreasing or the same, continue current rate
● If glucose increasing, give regular insulin 15 units IV push
Greater than 350 mg/dL and increase infusion rate by 2 units/hour 1 hour
● If glucose decreasing or the same, continue current rate
Decrease greater than
Decrease infusion rate by half the current rate 1 hour
100 mg/dL at one time
Department of Clinical Effectiveness V2
Approved by the Executive Committee of the Medical Staff on 12/12/2017
 Page 5 of 6
Hyperglycemic Emergency Management (DKA/HHS) - Adult
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into co nsideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers .

SUGGESTED READINGS

De Beer, K., Michael, S., Thacker, M., Wynne, E., Pattni, C., Gomm, M., ... & Ullah, K. (2008). Diabetic ketoacidosis and hyperglycaemic hyperosmolar syndrome–clinical
guidelines. Nursing in critical care, 13(1), 5-11.

Kitabchi, A. E., Umpierrez, G. E., Fisher, J. N., Murphy, M. B., & Stentz, F. B. (2008). Thirty years of personal experience in hyperglycemic crises: Diabetic ketoacidosis and
hyperglycemic hyperosmolar state. The Journal of Clinical Endocrinology & Metabolism, 93(5), 1541-1552. doi:10.1210/jc.2007-2577

Moghissi, E. S., Korytkowski, M. T., DiNardo, M., Einhorn, D., Hellman, R., Hirsch, I. B., ... & Umpierrez, G. E. (2009). American Association of Clinical Endocrinologists
and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes care, 32(6), 1119-1131. doi:10.2337/dc09-9029

Savage, M. W., Dhatariya, K. K., Kilvert, A., Rayman, G., Rees, J. A. E., Courtney, C. H., ... & Hamersley, M. S. (2011). Joint British Diabetes Societies guideline for the
management of diabetic ketoacidosis. Diabetic Medicine, 28(5), 508-515. doi:10.1111/j.1464-5491.2011.03246.x

Department of Clinical Effectiveness V2

Approved by the Executive Committee of the Medical Staff on 12/12/2017
 Page 6 of 6
Hyperglycemic Emergency Management (DKA/HHS) - Adult
This practice algorithm has been specifically developed for MD Anderson using a multidisciplinary approach and taking into co nsideration circumstances particular to MD Anderson,
including the following: MD Anderson’s specific patient population; MD Anderson’s services and structure; and MD Anderson’s clinical information. Moreover, this algorithm is not
intended to replace the independent medical or professional judgment of physicians or other health care providers .

DEVELOPMENT CREDITS

This practice consensus statement is based on majority opinion of the Hyperglycemic Emergency Management work
group at the University of Texas MD Anderson Cancer Center for the patient population. These experts included:

Conor J. Best, MD (Endocrine Neoplasia and HD)Ŧ

Jeffrey Bruno, PharmD (Pharmacy Clinical Programs)
Neetha Jawe, MSN, CCRN, CNL, RN (Nursing ICU)
Tami N. Johnson, PharmD (Pharmacy Clinical Programs)
Victor R. Lavis, MD (Endocrine Neoplasia and HD)Ŧ
Egbert Pravinkumar, MD (Critical Care and Respiratory Care)Ŧ
Anita M. Williams, BS♦
Sonal Yang, PharmD♦

Ŧ
Core Development Team
♦
Clinical Effectiveness Development Team

Department of Clinical Effectiveness V2

Approved by the Executive Committee of the Medical Staff on 12/12/2017